Health Committee on April 18th, 2016

[The Chair, Liberal, Bill Casey]

You can ask a really short one.

[Rachael Thomas, Conservative, Lethbridge, AB]

Okay.

I guess I'm simply looking for some help with regard to understanding. Right now health care is, of course, given to the provinces, so I am looking for help in terms of understanding how the federal government can impose a one-payer system on the provinces. In terms of respecting the system that's been set up in our nation, how do we move forward toward a pharmacare system, if that's what we choose to do?

[Dr. Marc-André Gagnon]

When it comes to jurisdiction, pharmaceuticals are a bit of a problem because health care establishment is a provincial jurisdiction. When it comes to drugs, there's nothing in the Constitution, except that legal substances or illegal substances are to be decided by the federal government. It is the role of Health Canada to approve new medications. When it comes to pricing of the drugs as well, it's with intellectual property, the patent system, which is also with the federal government. So like it or not, the federal government already has two feet in the jurisdiction of pharmaceuticals. But yes, absolutely, in terms of moving forward, we need to have the collaboration of the provinces. Right now we have some great steps with the pan-Canadian Pharmaceutical Alliance, basically a creation of the provinces, wanting to move forward. Right now there's an open hand, basically, from the provinces, and I think the context is just great to build this collaboration to move forward with the provinces.

[Rachael Thomas, Conservative, Lethbridge, AB]

Thank you.

[The Chair, Liberal, Bill Casey]

The time is up.

Mr. Kang.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, Mr. Chair.

Thanks to all the witnesses for coming here today to enlighten us on the things that we probably don't know.

Dr. Martin, you were talking about patients demanding drugs from doctors. I have a family doctor, and whenever a patient walked in and said “I need this medication, Doctor”, he used to say, “I'm the doctor. You're not the doctor, so you don't tell me what to give you.”

I believe there is some abuse in prescribing medications. What kind of abuse is there in the system, when doctors are caving in to the demands of the patient and writing something the patient may not even need, or may end up writing a prescription for an expensive drug the patient may request? What kind of abuse do you think could be there in the system?

[Dr. Danielle Martin]

Thanks for the question.

There has been quite a lot of study done on what influences the prescribing decisions made by physicians, and also what influences the demands patients make. In fact, one of the most powerful forces in prescribing in present-day North America is the influence of industry.

Some of you who have been following the news recently may be aware that there's quite a lot of controversy about the relationships between the pharmaceutical industry and physicians, and the ways in which industry can influence the prescribing decisions of physicians, such that as a medical community—and certainly as a medical educator I know that this is the case with our educational programs—we are increasingly trying to move away from allowing industry to have a big influence on the way we educate physicians about how to prescribe. Again, we want those decisions to be made based on medical evidence as opposed to marketing. Some of the marketing that goes on can be linked to education, or the education can be linked to marketing, in ways that I think are increasingly making the medical profession uncomfortable.

Similarly, there's quite a lot of evidence with respect to direct-to-consumer advertising. As you probably know, it's not legal currently in Canada for pharmaceutical companies to advertise their products directly to Canadian patients, but Canadian patients tend to consume a lot of that advertising through American television and other sources, and that can also have an influence.

But actually, one of the many things that influence prescribing decisions among physicians is habit. There are many thousands of drugs on the market today, and most of us get comfortable with a number of them. We really understand the side effects and the mechanisms and how they interact with other drugs or whatever. Most physicians tend to prescribe the same small number of drugs over and over again. That's why we need to make sure that the education we get from the outset is based on sound evidence, and use the formulary to make sure that those initial decisions we make are good ones, and then educate patients. I actually think that some interchange between physicians and patients about prescribing is good. I welcome my patients questioning me and pushing me about what they want to have, but those conversations need to be based on the best medical evidence as opposed to marketing from industry, and I think that's where some improvements need to be made.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

I could go on and on about this.

My next question is for Mr. Morgan.

Say we bring in pharmacare. Everybody should be covered. There should be no deductibles. You were saying something about people being allowed to have private insurance on the side in case the medication they need is not covered under pharmacare. Here we're trying to come up with one universal coverage, but at the same time, we are opening the door a crack for a little private coverage on the side, too.

Should we have that little private coverage on the side? That's my first question.

My second question is, should there be any means test to stop abuse? If it's free, people will think they should be able to get any medication.

I just finished talking with Dr. Martin about doctors caving in to the pressure of the patients, right? There will be some abuse of the system. Don't you think there should be some means test?

[Dr. Steven Morgan]

I strongly disagree with means testing of a universal drug benefit.

If a drug is deemed to be safe and effective at addressing legitimate health care needs and it represents value for money from a public health care system perspective in how we address those health needs for a Canadian, it shouldn't matter where they live, where they work, and what their income is in terms of their accessibility for that medicine.

There have been a number of provinces in recent years that have implemented income-based drug plans, otherwise known as catastrophic drug coverage, under the idea that we shouldn't be giving medicines away for free to people with higher income.

There are two problems with that. One, as I mentioned earlier, it means that everyone faces charges, or people with a higher income face charges that may dissuade them from taking the very medicines we really want them to take, preventative medicines that keep them out of hospital. The second problem is it breaks down the willingness of those with middle and upper incomes to support a universal drug benefit: they pay higher taxes, so shouldn't they also get essentially equal benefit? There are clinical, economic, and perhaps ethical grounds to avoid means testing of a drug benefit.

I think on those grounds what we want to think about is that it's a paradigm shift for Canada. It's changing our dialogue about pharmacare from which particular Canadians are going to have access to virtually every drug to which particular drugs are so deserving that every Canadian should have access to them.

Under that latter model—and I know Danielle has written about these sorts of options—we could envision building pharmacare in planned stages, probably using a planned budget increment, starting maybe at $10 billion for the national program, perhaps as much as $2 billion of which would come from the federal government and the remaining money from provinces and through other contributions, like copayments, and moving towards the $20-billion or $25-billion program down the road that we would need for truly comprehensive coverage.

As you rolled it out in that kind of planned fashion, of course there would be room for the private insurance industry to continue to offer drug coverage for things that aren't in the first phases.

If all of the evidence that we've gathered from other countries is correct, I believe that Canadians will actually see that a program can demonstrate value as it's rolling out. As a consequence, I think you will find that Canadians will continue to support the program and support its expansion.

[The Chair, Liberal, Bill Casey]

Mr. Webber.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair.

Thank you, all, for coming today. I appreciate it, particularly Mr. Gagnon, and your summary sheet that you distributed to all of us before this meeting today.

I appreciate that, Chair, and I just want to perhaps suggest that for any one of our future guests who come here, is there any possible way we can get documents from them, their reports?

Robert mentioned the “Pharmacare 2020” report by Mr. Morgan. That will be released to us. It certainly would have been nice to get that beforehand.

My suggestion is that at any future meeting, if we can get as much literature as we can, I would certainly appreciate that.

[The Chair, Liberal, Bill Casey]

I don't know. I'd like to have copies of all their presentations if that's possible, because they were really.... That's a start.

[Len Webber, Conservative, Calgary Confederation, AB]

Yes, exactly.

Again, thank you all for coming.

Mr. Morgan, I was interested in hearing your comments about the number of diabetics who are dying because they choose not to purchase medication. Perhaps because of low income, they can't afford the medication.

I don't know too much about catastrophic drug plans and how they work, but each province is responsible for catastrophic drug plans. Could you talk a bit about how the catastrophic drug plans kick in?

[Dr. Steven Morgan]

Yes, every province is responsible for its own drug benefits. We have no binding commitments between the federal and provincial governments around national standards, and so provinces run their own programs, which are very different.

Ontario, which is where that study was conducted, offers relatively comprehensive—in fact, “Pharmacare 2020”-like—coverage for persons age 65 and older. Under the age of 65 people in Ontario fall into the mix of private and public coverage that has been standard in Canada for so many years: voluntary private insurance for people who work in occupations that offer that as an extended health benefit, and then catastrophic coverage from the province for people who don't have private insurance.

That catastrophic plan which Danielle described has a 4% of household income deductible, which is thousands of dollars. It was an interesting study scientifically. In that Ontario study they compared people younger than 65 with diabetes with people just over 65 with diabetes and used the change in benefit structure that comes with that age of being entitled to public coverage as the mechanism of demonstrating the value or the increased access that comes with coverage. It is on that basis they were able to infer the number of diabetics who are skipping their medicines because of the costs when they are under 65 versus those over 65 who don't face those barriers. It is from that they were also able to infer the premature deaths.

I have similar work coming out later this summer from British Columbia looking at a similar study design based on our income-based drug plan, which has an accident of history. People born in 1939 or older got better coverage than people who were born after that date, and it's because in some sense they literally grandfathered the more comprehensive coverage that B.C. used to provide for seniors.

[Len Webber, Conservative, Calgary Confederation, AB]

Interesting. Please finish that report and let us have it.

[Dr. Steven Morgan]

I'm sure we all have probably a half dozen we can send you over the course of the coming months.

[Len Webber, Conservative, Calgary Confederation, AB]

Yes, exactly.

I want to talk about our provinces and the silos in which we tend to work within our health care system, and the fact that a universal pharmacare purchasing power, by bringing all the provinces and territories together, would certainly be beneficial.

Mr. Gagnon, on your statistics with regard to how Canada ranks very poorly when it comes to drug costs and such, it just makes sense that we come together as a country to purchase our drugs.

I'm going to mention organ and tissue donation. There is clear evidence that our provinces and territories work in silos with respect to sharing organs and tissues, and I find it very frustrating. We, as the federal government, should work toward having an overarching system as well when it comes to organ and tissue donation. I know we are talking about pharmacare here, but it's just the attitude. Mr. Gagnon, you said it is constitutional, that the provinces have their jurisdictions and that the feds should not step into their jurisdictional areas, but I think this is something that all provinces and territories need to discuss and they need to move forward with bulk purchase power buying.

I think about Quebec, for example, who run their own—I'm back to organ and tissue again. There is very much a silo in Quebec when it comes to organ and tissue donation. I just don't understand it.

Ms. Prémont, with your experience in Quebec, maybe you could talk about why there are silos throughout the country, in particular in Quebec.

[Dr. Marie-Claude Prémont]

This is a very important question that you're asking. I think this is one that we did tackle historically as a country. Don't forget that the Constitution says hospitals are under the jurisdiction of the provinces. It's specifically written, yet we did manage to implement a public health care system across the country, respecting the Constitution and the jurisdiction of the provinces.

I don't know what should stop us from doing the same thing with drugs. We just need to have a bit—maybe a lot—of the political will to go ahead, I think, in facing the difficulties that every single province is facing now with this, and which Canadians are facing with the current situation. I include Quebec in that, because people recognize more and more that the system is not sustainable. The cost has been increasing steadily since its implementation. The portion that was supposed to be self-funded is really obviously not self-funded, far lower than 30%.

I agree with Steven that now is the time to get our act together, including Quebec. I don't speak for Quebec, of course. I only speak on my own here, but I think the time is right to revisit that and see how all the provinces and territories should get together to improve the situation of every province.

[Len Webber, Conservative, Calgary Confederation, AB]

Yes, absolutely.

[The Chair, Liberal, Bill Casey]

The time is up.

Dr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair.

Thank you all. These were amazing presentations. They gave data to things that I had thought intuitively were the case from my medical practice. I've had anecdotes, and Dr. Martin, you could probably share many of these with me as well, of treating a patient with diabetic ketoacidosis in the emergency department when they couldn't afford their insulin. If that patient ends up in the intensive care unit, the cost for that one hospital visit probably exceeds a lifetime of that patient's insulin. That being said, we also know that the plural of anecdote does not equal data.

It's believed by many practitioners that the initial investment of a pharmacare program would eventually be offset by savings to the system, by just improved health and decreased hospital costs. In any of your reports, is there any data or any numbers that could say what the upfront costs, the ongoing costs, and the long-term savings would be to the public purse for such a program?

[Dr. Steven Morgan]

I'll take that on because of the study that we published in the Canadian Medical Association Journal about how much it would cost to provide a reasonably comprehensive drug benefit for the community in Canada. That's not including hospitals and long-term care, but in retail pharmacy we estimated that the direct increased cost to governments was $3.4 billion, if I recall correctly, $2.4 billion of which would be recouped in some sense by reduced cost of the taxpayer-financed extended heath benefits for public sector employees, including, likely, all of you and myself. It's about $3.4 billion to expand the program and to generate about $8 billion in savings to the private sector by way of reduced need for them to be paying either out of pocket for their medicines or a reduced demand on private insurance for drugs.

In and of itself, the program paid for itself. But we didn't—and we make note of this in the Canadian Medical Association Journal article—take on the second argument that you are raising, which is a very important one, the argument about the incremental effect on our health care system. There are very good trials that have demonstrated that lowering the copayments for even relatively wealthy insured beneficiaries of private insurance in the United States improves access to preventative treatments and reduces the demands on medical and hospital care sufficiently so that, in the U.S. market, that's revenue neutral, not accounting for the savings in prices that one gets for it.

It's almost certain that this program would pay for itself, in some sense twice, once by way of increased purchasing power, and twice by way of better health for patients and therefore a reduced demand on the health care system.

Do I think we're going to see savings actually realized in health care? No. But I think we'll see health care resources being able to address other unmet needs in health care, and that would be a great thing for Canadians.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

All right, thank you. As I say, it's nice to know my assumption actually had some basis to it.

Dr. Martin, one of the things I've noticed, and again, I have noticed it in my individual practice, is that doctors very often when they write prescriptions know that patients are going to have trouble affording medications. I practised emergency medicine in the core of Winnipeg where there are a lot of poor patients.

Would you say doctors are spending a significant amount of time on workarounds to try to make sure their patients can afford the medications they need?

[Dr. Danielle Martin]

Thanks for the question.

In fact, we've just completed a study on this that is under peer review and we hope will be published relatively soon. In that study we looked only at family physicians, including family physicians who practise emergency medicine, but I suspect that the data for specialists will not be all that different. We did find, unsurprisingly, that physicians report quite a lot of time spent, and quite complex—what I think of as unnecessary—workarounds to try to get medicines for their patients.

The kinds of examples that I referred to in my presentation are not just anecdotal from my own practice, but come from qualitative research and from speaking to family physicians across the country who talk about the kinds of things that they have to do. They talk about giving patients samples and interacting with drug reps in order to get samples, changing the prescription that they're writing from the medicine that they think their patient actually needs to the one that they think their patient is actually going to be able to afford, applying on behalf of their patients for compassionate access through a pharmaceutical company for a medication that their patient can't afford, and just purchasing the medicine for the patients themselves. It's amazing how many physicians will report that at some point in their career they've done exactly that, just bought the medicine for the patient. Pharmacists, I know, report the same thing. You know the old story: “Don't worry, I'll just tell my boss that I dropped it on the floor and had to throw it out. Don't worry about it. Just take the pills home.”

There are all kinds of workarounds that are going on that well-meaning health care providers are engaging in across the country in order to try to get access to medicine for Canadians who need it. When you think about the wasted—never mind the wasted money—energy that it entails, that energy would be much better spent directed at patient care. I think it just adds to the importance of this conversation.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you very much.

Thank you, Mr. Chair.